The U.S. Surgeon General released a special report on mental health related to culture, race, and ethnicity in 2001. The report emphasized the influence of culture on many aspects of mental illness, including how people from a given culture communicate, cope with stress, and manifest symptoms of mental disorders. The report also noted that mental health professionals and the systems that provide care have their own unique cultural values and practices that influence the kind of care patients receive.¹ One definition of mental illness is behavior which deviates from the norm,² but in today’s culturally diverse healthcare environment, one cannot merely assume a particular norm. Nurses confront cultural issues related to mental health that do not conform to the norms of what is now often referred to as the majority culture, not only in psychiatric settings, but in many different healthcare arenas. Since culture shapes responses to illness and treatment, culture not only guides the level and progress of patient recovery,³ but what can be defined as “normal behavior. Nurses in all specialties need to be sensitive to their own cultural bias, as well as the perspectives of their patients. Here are some examples:

Postoperative setting: Nurses caring for an elderly Italian widow notice that her unmarried adult daughter hovers over her mother constantly. They discover that the daughter has never left home and spends most of her time taking care of her mother, who suffers from persistent depression. The nurses describe the situation as “pathological codependence.” According to their (majority) culture, they define the daughter’s behavior as abnormal. A new nurse on the unit disagrees saying, “It’s culturally appropriate in traditional Italian culture for a daughter to stay home with a chronically ill mother. In other words, the nurses’ labels of what is normal or abnormal may not apply in this particular situation. This new nurse spends some time with the daughter, finding out more about her role in the family and Italian expectations regarding her responsibilities toward her mother.

Outpatient clinic: When the nurse asks mental health screening questions, a Haitian immigrant admits to believing he is hexed and doomed to die. Upon further exploration, the nurse suspects a delusional disorder. When seeking corroborating information from the family, the nurse learns that a cousin had put a hex on the patient. The whole family believes this to be so. Later, the nurse reads up on culture-bound syndromes to discover that hexing, voodoo, and rootwork are common in a number of different cultures. She finds an article about this culture-bound syndrome and posts it for the staff to read. Later, the staff meets with some leaders from the patient’s community to discuss possible culturally appropriate ways to deal with this problem.

Psychiatric setting: A nurse is working on interpersonal skills with a young Asian woman who has been diagnosed with schizophrenia. He encourages the patient to make direct eye contact during interpersonal interactions. Another nurse from the same cultural background as the patient points out that direct eye contact is considered rude in her culture, especially when a younger person is speaking with an older man. In the next staff meeting, some of the cultural implications of eye contact are discussed. The staff explores ways of dealing with the normality of eye contact, including culturally appropriate ways to ask patients what is normal in their culture.

Why be concerned about culture and mental health?

Because mental health concerns human behavior and interaction, cultural understanding is especially important. Culture determines the behaviors that are considered normal or abnormal, the beliefs and values deemed important, and the rules that direct human interaction. Not only are behaviors important, but so are their situational contexts, along with a host of other practices, such as personal hygiene, dress, hairstyle, and religious beliefs and values. When caring for patients, nurses need to be aware of cultural variations in what is deemed appropriate or inappropriate, as well as understand how patients from particular cultures may display mental distress.⁴ For example, one study of South East Asian Refugees (i.e. Cambodian, Vietnamese, Hmong, and Laotian) contrasts the Asian and Western manner of describing psychological distress. In Asian classification of disease, depression is usually presented as problems with eating and sleeping; feeling tired and irritable; and having headaches, backaches, or digestive problems, whereas in Western culture, depression is described more in terms of sad affect.⁵ The authors point out that because of the tremendous cultural differences in expressing cultural problems, it is important to choose assessment tools that are conceptually valid for the patient.⁵

Assessment of cultural factors impacting on the patient’s care is a requirement of the Joint Commission on Accreditation of Healthcare Organizations. The patient’s culture represents a potential barrier to the achievement of his or her healthcare goals, and cultural considerations need to be incorporated into the patient’s nursing care plan to ensure an optimally effective hospitalization.⁶ This is especially true for the mental health patient who is likely more highly sensitized to the cultural aspects associated with his or her care.

Just as each culture has its own communication style with speech, body language, and gestures, specific cultures also have their beliefs about individuality, autonomy, and group identity. For example, some cultures value group cohesion over individuality, while others emphasize individuality and competition. Cultural groups also have different ideas about their relationship to nature and the environment, and even toward the past, present, and future. Taken all together, these beliefs and practices constitute a worldview, or a way of seeing and experiencing life. Differing worldviews may conflict with what we, as nurses, view as desirable or healthy, so it’s important not to make assumptions based only on our own cultural background.

The following example illustrates how values enter into how nurses may interpret a situation. A 2-year-old Mexican immigrant boy was having major cranial-facial corrective surgery. His entire extended family, including parents, grandparents, a couple of aunts, and several young children, came to the hospital. They rented a nearby hotel suite for the duration of the child’s hospitalization and rehabilitation. At the same time, the child of parents of a northern European heritage was having similar surgery. These parents, valuing privacy and independence, made a point of limiting any information about the child’s condition to anyone outside of the immediate family. They cautioned nurses to keep the situation confidential. They also kept their distance from the staff and even from the child, while he was very sick. From a mental health perspective, nurses unfamiliar with the Hispanic tradition of cohesion within the family, especially when trouble strikes, could consider this family as too enmeshed. They could be annoyed, feeling that the family might interfere with the child’s care. On the other hand, nurses unfamiliar with values of autonomy and independence held by the second family could label them as cold or uninvolved. But in each case, the family style of dealing with a stressful situation simply reflects different cultural values.

Every culture has its own set of values. Values are principles, beliefs, and practices that are considered intrinsically desirable. Cultural groups instill values during early childhood training, and people grow up to accept these as the way things should be. Most of us are unaware of our own value systems. Because these values are so deeply imbedded into our own view of life, we need to take the time to examine how they influence the way we interpret things. Culturally based values may determine how we believe things should be done within our culture, but we must also recognize that these learned values might differ from those of people who belong to other groups. In Westernized societies, professional notions of healthy behavior and appropriate interaction reflect many of the values of the dominant, mainstream American culture inherited from Northern European ancestors; however, these values may not fit with the cultural expectations and norms of groups with other cultural heritages.

The practice of mental health nursing is steeped in mainstream values. The core cultural values nurses tend to sanction as healthy belong to this group. A culturally competent mental health nurse understands that these mainstream values might differ or even clash with the value systems, beliefs, and practices that other groups view as normal or healthy. Openness to accept the validity of other views of normalcy is a crucial step to becoming culturally competent in mental health nursing.⁷ When we are unable to recognize that our own deeply held values may differ from those of our patients, the therapeutic nurse-patient relationship is jeopardized and the accuracy of assessment and effectiveness of nursing care is adversely affected.8 Being different is not necessarily a sign of being abnormal.

Values underlying mental health nursing

Mental health professionals typically hold four values. However, these values can easily differ from those held by patients in other cultures.

1. The Connection Between Mind and Body: Western culture has differentiated between the mind, or psyche, and the body, or soma. This is known as mind-body dualism. Practice specialties that have evolved both in medicine and nursing have reflected this separation. Psychiatric specialties deal with disorders in behavior, emotions, and mental functioning, whereas medical and surgical specialties deal with so-called physical problems. Some cultures do not make such a clear distinction between the mind and body. People in these cultures perceive that illness has simultaneous physical, mental, and spiritual components.⁹ For example, Arab Muslims see physical health as integral with the spiritual dimension. Similarly, Latino and other cultures do not distinguish between mind and body; instead, a special form of cultural somatization takes place.

The term somatization refers to the cultural patterning of psychological distress in a language of mainly physical complaints. Distress is communicated through the body.⁴ Instead of saying, “I am very stressed, and things aren’t going well for me,” a person might focus on generalized body pains, stomachaches, or heart pain. This “pattern of speaking with the body” is common throughout the world. In cultural somatization, a particular organ in the body becomes the main focus of all symptoms and anxiety. The organ chosen often has symbolic meaning for the cultural group. For instance, in Iran, distress is communicated through the heart as “heart distress.” In France, it is the liver, and in the United Kingdom, the bowels. The Chinese focus mainly on somatic symptoms because, in their culture, emotional distress is connected to disturbances of the organs and their functions. In other words, harmonizing bodily functions is the key to alleviating emotional distress.⁴

2. Autonomy and Independence: In the first clinical example given at the beginning of this module, most of the nurses saw the mother-daughter relationship as codependent and unhealthy. This view reflects a core value typically held by mental health professionals in the U.S., where autonomy and independence are reflections of mental health. Healthy behaviors are equated with being “on your own,” that is, being self-sufficient, having initiative, and achieving individual success. Being subsumed in a group or being deeply connected and dependent on immediate and extended family is perceived as less desirable, thus less healthy.

Western culture is in the minority when it comes to valuing individuality. Many cultures place much more emphasis on the welfare of the group and not standing out in a position superior to others; they value cooperation above competition. Asian, Native American, and Hispanic societies, in particular, stress group identity and family loyalty over autonomy and independence. For example, Asian Confucian philosophy stresses the value of promoting the respect and harmony among family members in the belief that this leads to harmony within one’s self. These values produce a different approach to problem solving than that followed by Westerners. Instead of attacking problems directly, which is common in Western culture, Asian cultures tend to accommodate and/or deal with problems indirectly. They avoid conflict and achieve balance and harmony between the family and the larger environment.¹⁰

3. Control Over the Environment and the Predominance of Science: Another core value prevalent not only among mental health professionals, but throughout Western society in general, is the belief that science and medicine can control the environment, nature, and illness and that this control is desirable. The scientific tradition is paramount; indeed, the scientific paradigm has stretched to include almost every conceivable sector of Western life. Likewise, the practice of medicine permeates every facet of life, including birthing, child rearing, diet, exercise, safety, stress reduction, and decisions about death and dying. Avoiding diseases and accidents is a cultural preoccupation. People are held responsible for their illnesses or for failing to seek the right treatment. People are encouraged to “fight” their illness even when death is inevitable. Madeleine Leininger, RN, PhD, a nurse anthropologist famous for her groundbreaking work in transcultural nursing, noted that metaphors used to describe medical interventions reflect the value we place on conquering illness and death. For example, we refer to “fighting” a disease, or “using aggressive therapy.”⁷ Not all cultures believe in this level of control over the environment. In fact, people in some non-Western societies would find it strange that such behaviors as adjustment problems and substance abuse have been classified as psychiatric disorders. Even in Western society, critics of diagnostic labeling point out the danger of confusing illness with normal functioning. Grief is an example. Normal grief in many cultures manifests itself like a major depression or other “crazy-appearing” behaviors. Behaviors associated with grief among different cultural groups vary greatly, ranging from screaming, wailing, and loss of control to very quiet, stoic behavior. In many cultures, fate, that is, inevitable adverse events and their consequences, is expected. Bad events happen, and that is accepted as part of life.

4. Orientation to Time and Future: A final core value is the view that action and change are signs of positive growth. This value is imbedded in an orientation toward the future, rather than the present or the past. Therefore, mentally healthy behaviors are seen in terms of skills oriented to the future, such as planning ahead, attaining specific goals within a particular timeframe, and working hard to meet anticipated new challenges. Inactivity and stagnation are signs of weakness. In mainstream Western culture, even leisure time should be filled with goal-directed activities. Our progress and future orientation is illustrated by the General Electric slogan, “Progress is our most important product.” Likewise, nursing care plans are oriented toward the future. We map out measurable goals for the patient to attain before discharge.

Yet some cultures are strongly oriented to the present, and others to the past or present/past. Native Americans and African Americans have a present-time orientation, while Asian Americans have a combination present/past time focus. Whereas Asians have valued the past and many worship or at least pay respect to their ancestors, U.S. culture values youth over the elderly.¹¹ Accordingly, if a patient’s time orientation differs from that of the nurse, there may be a different orientation toward the pace of treatment, which may seem to be going too slowly for those with future orientation and too fast for those with present or past orientation. For example, the Native American’s present orientation and view of time as a flowing, circular, or as a harmonious dimension may find the division of time into schedules disruptive and feel rushed by a future, “results-oriented” nurse. The tardiness of some Latino patients may frustrate nurses who haven’t learned that time to many Hispanics is also flowing and indefinite.

What are culture-bound syndromes?

Not only are professional values culturally bound, but the classification of psychiatric disorders is in itself culturally value laden. Many Western-oriented countries use the American Psychological Association’s (APA) Diagnostic and Statistical Manual (DSM-IV) as a guide for diagnosing mental disorders.¹² Although this diagnostic system purports to be only descriptive, it still reflects a system where an illness is created simply by agreeing on operational criteria. Syndromes are added and removed based on the consensus of experts.¹³

Because behavioral health research is still evolving, this may be the best we can do at this point in time. Still, we should recognize that other cultures have also identified syndromes. These might sound strange to us, but think about how strange some disorders might sound to those unfamiliar with mainstream Western culture. School phobia, anorexia nervosa, attention deficit disorder, and borderline personality disorder are some examples of syndromes unique to Western societies.

Culture-bound syndromes are “folk” conceptualizations of patterns of mental disorders. They usually do not conform to conventional diagnostic syndromes, yet they have cultural validity in the societies in which they occur. They are thought of as culturally symbolic idioms of distress, which means responding to stress or showing distress in a style that makes sense in a particular society.^14,15

The DSM-IV includes an appendix that contains the best-studied culture-bound syndromes and idioms of distress that may be encountered in clinical practice. Five of the more common syndromes are discussed here as examples.

Amok: Originating in Malaysia, amok is a dissociative episode accompanied by violence toward people or objects, persecutory ideas, amnesia, and exhaustion. The outburst happens after a perceived slight or insult and is seen only in men. A similar behavior pattern is found in Laos, the Philippines, Polynesia, Papua New Guinea, and Puerto Rico, as well as among the Navajo. The expression “running amok” refers to this syndrome.

Ataquque de nervios: This syndrome is seen in Latinos from the Caribbean, as well as other Hispanic groups. Symptoms include uncontrollable shouting, crying, trembling, and verbal or physical aggression. Dissociative experiences, seizure-like or fainting episodes, and suicidal gestures can also occur. This constellation of symptoms frequently occurs after a stressful event relating to the family, such as a loss, separation, divorce, or an accident involving a family member.

Hwa-byung: Literally translated as “anger syndrome,” this is a fairly common disorder experienced in traditional Korean culture and is diagnosed and treated by Korean psychiatrists. Insomnia, fatigue, panic, fear of impending death, lack of appetite, “bad” mood, heart palpitations, and generalized aches and pains are its main symptoms. Patients complain of feeling a mass in the stomach. From the traditional Korean perspective, this condition is seen as an imbalance in the relationship between basic elements of life. Anger is a manifestation of lack of harmony.

Taijin Kyofusho: This disorder is an official psychiatric diagnosis in Japan and closely fits the APA diagnoses of social phobia or obsessive-compulsive disorder. Rooted in the value that traditional Japanese culture places on proper social behavior and decorum, the symptoms experienced include concern that the patient’s body, its parts, or its functions are unpleasant or offensive to other people. Concern is felt over appearance, body odor, facial expression, or movements. The disorder is so prevalent that social support groups have been developed for those who suffer from the condition.

Rootwork, Hex, and Voodoo: The second clinical example at the beginning of this module referred to a case in which both the patient and her family believed that she was hexed and doomed to die. The nurse suspected a delusional disorder. Rootwork, hex, and voodoo refer to cultural beliefs that an illness is due to hexing, witchcraft, sorcery, or evil influence brought about by another person. These traditional beliefs have existed throughout human history and persist even now among people in both developing countries and in modern, developed parts of the world. A distinction is often made between natural conditions that can be expected as part of God’s plan and unnatural diseases that are the result of disharmony or conflict with God’s will or the result of evil influence. Symptoms may include generalized anxiety, nausea, vomiting, diarrhea, weakness, dizziness, and fears ranging from fear of being poisoned to fear of being killed (voodoo death). Rootwork, referring to the use of dried roots of plants in charms and spells, is found in the southern U.S. among both African-American and European-American populations and in Caribbean societies. It is also known as mal puesto or brujeria in Latino societies.

These common examples of culture-bound syndromes illustrate the notion that behaviors, emotions, and expressions of distress are deeply rooted in cultural influences. Other examples are listed in the DSM-IV. Nurses need to see beyond Western interpretations of mental distress and mental disorders and recognize that there is a wide range of behavioral patterns when dealing with persons from cultures different than their own.

How nurses can transcend cultural values

There are several ways that you, as a nurse, can endeavor to transcend cultural values when working with patients who have mental health problems. The following are suggestions for supportive actions that the nurse can take to give mental health care that is culturally appropriate.

1. Become aware of your own professional and personal values about mental health. The professional values instilled through our nursing education along with our own cultural values and notions influence our ideas about mental health.¹⁶ Begin by identifying some of these values. What are some of the beliefs and practices of your own cultural heritage? How do people in your culture express distress and show signs of mental illness? What are some values you have adopted as part of your professional development? How might these be different from those of other cultural groups? Be even more specific when thinking about these things. For example, what is your attitude toward patients who express distress through somatization? How do you feel about people who express grief very openly in public versus those who express it stoically and privately? How does your view, in turn, affect your response to the patient?

It is important for nurses to honestly examine their own cultural biases. Naturally, we tend to think our beliefs and values are the correct ones. This ethnocentrism is common in all cultural and social groups. But, as professionals, it is our responsibility to transcend this bias. While we do not need to abandon our own values, beliefs, and cultural practices, we do need to understand how our perspectives may have an impact on our responses to patients and our assessment of their mental health needs.

2. Identify cultural nuances when assessing symptoms of mental disorders. Now that we have examined cultural values and culture-bound syndromes, it is easy to see how cultural and ethnic differences might lead to misunderstandings when assessing symptoms of distress or mental illness. Of particular concern are symptoms seen as abnormal in Western society, for example, lack of eye contact and an unresponsive or “flat” affect. These signs are often associated with schizophrenia or depression, yet in some cultures these are normal behaviors. Direct eye contact may be considered disrespectful in certain cultures, as illustrated in the third clinical example at the beginning of this module. Similarly, assessing affect requires knowledge of differences in cultural styles of expressiveness and interpersonal trust.¹² For instance, Native Americans may present with a less responsive affect.

Specific assessment techniques must always be used with caution. A good example is assessing abstract thinking by using proverbs, such as asking a patient what is meant by, “Don’t cry over spilt milk.” Proverbs are culture-dependent and shouldn’t be used to assess thinking ability.¹⁷ Jacquelyn Flaskerud, RN, PhD, a well-known nurse educator and expert in culture and psychiatric nursing, cautions that the tendency for mistaken assessment is more likely to occur when the nurse and patient do not share the same cultural meanings or language.¹⁸ The meanings we give to specific behaviors influence how we label that behavior. Nurses often describe patient behavior using psychiatric terminology, which may in itself lead to a psychiatric diagnosis. Remember that behaviors and beliefs considered psychotic in one culture may be normal in another. For example, in some cultures, believing an evil spirit possesses someone is a common experience. Be sure to compare the patient’s behavior with normative standards of his or her cultural group, not only with the Westernized diagnostic system.

One way to minimize cultural bias is to have people from the same cultural background confirm information about patients and participate in the patients’ assessment and care. If large numbers of patients in a healthcare setting come from a particular culture, ideally some nursing staff would be from that same cultural background. When this is not possible, nurses can learn as much as possible about the patients’ culture and convey to them that they are interested in their perceptions and experiences.

3. Seek to understand patients and their situations within the context of their social group. Although nurses are taught to view patients objectively as outside observers, culturally competent caregivers also assess from the inside view, that is, from the perspective of patients themselves and their social and cultural contexts. Ask questions about belief systems, perceptions about the cause of a problem, and how, in the patient’s culture, this type of problem is usually addressed. Inquire about religious and spiritual beliefs and experiences. Use the family, or, perhaps, community leaders of the same cultural background, to help in gathering information.

4. Remember that not all members of a particular culture are the same. It is easy to come away from this module with the inaccurate idea that all members of a particular culture are similar. Remember that information about cultural trends should never overshadow the understanding of the individual person.¹⁹ Be alert to and avoid stereotyping, that is, thinking that everyone in a particular cultural group is the same.⁸

Factors, such as length of time living in the U.S. or whether people live among a community made up of their own culture, greatly influence people’s behaviors. Education and social status are other important factors. But behind a person’s cultural background is a unique individual. The old maxim of psychiatric nursing holds true — the focus of a therapeutic relationship is on the individual patient and that patient’s needs.

5. Be understanding about patients who hold different values about time and appointments. As discussed earlier, many cultures do not perceive or organize time in the same way that we do in mainstream Western culture.

When people are distressed or suffering from a specific mental disorder, it sometimes becomes even harder for them to meet schedules and appointments. Nurses need to become more creative in meeting these patients’ needs. One idea is to hold clinics in a more free-flowing style, such as inviting patients to come in for assessments and symptom-monitoring check-ups between a three- or four-hour timeframe on certain days of the week. Another idea is to set up a seamless flow of care so that the patient does not need to come in at different times for laboratory tests or medication adjustments. A friendly reminding phone call may be helpful, as well.

It is so important to maintain a “user-friendly” setting. A caring atmosphere will improve compliance with appointments. Most of all, we need to be tolerant of differences and try to understand other perspectives.

6. Remember that empathy goes a long way in bridging cultural differences. In today’s busy healthcare arena, we sometimes forget how important it is to convey a caring attitude toward patients. Through a caring approach, we can enhance the nurse-patient relationship to a level of trust necessary for self-disclosure, especially when sharing personal distress and symptoms of mental illness. One way to be empathic is to show interest in cultural differences and acknowledge these with the patient. Presenting yourself to patients as a benign and interested partner who has their best interest in mind goes a long way to promoting cultural understanding.

To adequately serve mental health patients in today’s increasingly diverse environment, nurses can be guided by the useful mnemonic ASKED, developed by Josepha Campinha Bacote, RN, PhD, FAAN, president and founder of Transcultural C.A.R.E. Association. These questions, which are now widely used in physician and nursing education, serve as an excellent reminder of the awareness, knowledge, and skills of the culturally competent caregiver.

Awareness: Am I aware of my personal biases and prejudices toward groups different than mine?

Skill: Do I have the skill to conduct a cultual assessment and perform a culturally based physical assessment in a sensitive manner?

Knowledge: Do I have knowledge of the patient’s worldview and the field of biocultural ecology?

Encounters: How many face-to-face encounters have I had with patients from diverse cultural backgrounds?

Desire: What is my genuine desire to “want to be” culturally competent?²⁰